What are the symptoms and management of chronic bronchitis?

Symptoms of Chronic Bronchitis

Chronic bronchitis is defined by chronic cough and sputum production occurring on most days for at least 3 months of the year for at least 2 consecutive years, after excluding other pulmonary or cardiac causes. 1

Cardinal Symptoms

The hallmark clinical presentation includes:

• Chronic productive cough - the defining feature, with sputum expectoration occurring most days for the required duration 1
• Excessive mucus production - chronic or recurrent mucous hypersecretion in the bronchial tree 1
• Progressive dyspnea - worsening shortness of breath, particularly as airflow obstruction develops 1

Acute Exacerbation Symptoms

When stable patients experience sudden clinical deterioration, they develop an acute exacerbation characterized by:

• Increased sputum volume - a key cardinal symptom of exacerbation 1
• Sputum purulence - change in sputum color/quality indicating possible bacterial infection 1
• Worsening dyspnea - acute increase in shortness of breath 1
• Preceding upper respiratory infection symptoms - exacerbations are often preceded by URI symptoms 1

Important caveat: Other conditions mimicking acute exacerbations must be excluded, including pneumonia, pulmonary embolism, pneumothorax, and congestive heart failure. 1

Pathophysiologic Basis of Symptoms

The symptoms arise from multifactorial mechanisms:

• Airway inflammation - chronic inflammation in airway walls and lumen activates the afferent limb of the cough reflex 1
• Heightened cough receptors - capsaicin-induced cough is increased in chronic bronchitis patients, demonstrating receptor hypersensitivity 1
• Impaired mucociliary clearance - abnormal clearance leads to mucus retention and creates a vicious cycle of chronic recurrent coughing 1
• Ineffective cough mechanism - when airflow obstruction develops, decreased expiratory flow coupled with impaired mucociliary clearance results in further secretion retention 1

Associated Clinical Features

Beyond the cardinal symptoms, patients commonly experience:

• Frequent respiratory infections - patients have greater frequency of acute respiratory infections than those without bronchitis 1
• Quality of life impairment - substantial decrements in quality of life, particularly during exacerbations 1, 2
• Progressive lung function decline - chronic bronchitis is associated with more rapid decline in lung function 2
• Increased exacerbation frequency - persistent chronic bronchitis correlates with greater exacerbation rates 2

Management Approach

Primary Intervention

The single most effective treatment is complete avoidance of respiratory irritants, with 90% of patients experiencing cough resolution after smoking cessation. 1

Stable Disease Management

For patients with persistent symptoms despite irritant removal:

• Short-acting β-agonists - should be used to control bronchospasm and relieve dyspnea; may reduce chronic cough in some patients 1
• Ipratropium bromide - should be offered to improve cough 1
• Long-acting β-agonist plus inhaled corticosteroid combination - should be offered to control chronic cough 1
• Inhaled corticosteroids alone - should be offered for patients with FEV₁ <50% predicted or frequent exacerbations 1
• Theophylline - should be considered to control chronic cough, but requires careful monitoring for complications 1

Not recommended for stable disease: Prophylactic antibiotics, oral corticosteroids, expectorants, postural drainage, or chest physiotherapy have no proven benefit. 1

Acute Exacerbation Management

When patients meet criteria for acute exacerbation (increased sputum volume, purulence, and/or dyspnea):

• Inhaled bronchodilators - short-acting β-agonists or anticholinergics should be administered; if no prompt response, add the other agent after maximizing the first 1
• Oral antibiotics - recommended for exacerbations, particularly in patients with severe exacerbations or more severe baseline airflow obstruction 1
• Oral corticosteroids - useful for acute exacerbations (IV corticosteroids for severe cases) 1
• Cough suppressants - codeine or dextromethorphan recommended for short-term symptomatic relief only 1

Not recommended for exacerbations: Theophylline, expectorants, postural drainage, or chest physiotherapy. 1

Antibiotic Selection Criteria

Antibiotics should be reserved for patients with at least one key symptom (increased dyspnea, sputum production, or sputum purulence) AND at least one risk factor (age ≥65 years, FEV₁ <50% predicted, ≥4 exacerbations in 12 months, or comorbidities). 3

Smoking Status Impact

The relationship between smoking and chronic bronchitis symptoms is critical:

• Persistent smoking - associated with persistent chronic bronchitis and worse outcomes 2
• Smoking cessation - confers 4.3-fold increased odds of symptom resolution 2
• Resumed smoking - associated with 4.6-fold increased odds of developing new chronic bronchitis 2

Clinical pitfall: Chronic bronchitis can resolve with smoking cessation but also newly develop or recur with continued or resumed smoking, emphasizing the need for repeated assessment of cough and sputum production in all smokers. 2